After years of rapidly rising spending on Britain’s National Health Service, a new age of fiscal austerity is about to dawn. Rising demands for health care from an aging population will have to be met out of what is effectively a static budget. The NHS will have to find savings of £20 billion out of a total budget of about £100 billion, according to its chief executive, Sir David Nicholson. Hence the attractions of transferring responsibility for commissioning services from Primary Care Trusts to consortia of general practitioners, the centerpiece of the new model.
It is GPs, after all, who generate and filter demands for expensive hospital care: in the U.K. all hospital referrals are routed through GPs (though there has been a rising trend in patients referring themselves to emergency departments). If GPs are directly responsible for budgets, they will have a direct incentive to develop alternative (and cheaper) services in the community and to be selective in their referrals. So runs the logic, at any rate.
A further political attraction is that in the decisions about how best to allocate resources will be seen as clinical, not managerial or political. The public, every survey shows, trusts doctors but not managers let alone politicians. So while there may be little reason to think that GP consortia will be more efficient than primary care trusts, as Tony Culyer pointed out in his recent post here, their decisions should be more acceptable, putting a screen between the politicians who determine the NHS’s resources and the consequences at the coalface. Or so at least Ministers may hope.
The logic is not new. Twenty years ago Margaret Thatcher introduced GP “budget holding;” i.e., GPs practices could opt to hold a budget, set by the government, from which to buy services for their patients. It is the radical, disruptive scale of the proposed change that is new. Interestingly, the medical profession is sharply divided.
While some GPs welcome the new model as an opportunity to innovate and show some muscle vis-à-vis the hitherto dominant hospital providers, others see it as a poisoned chalice for precisely the same reasons that it appeals to Ministers – that it will force them to take the hard decisions involved in managing scarce resources at a time of rising demand. GPs see themselves as the patient’s advocate and are reluctant to become responsible for rationing: deciding what should be available to whom.
The role will be all the harder now that the NHS’s traditional way of coping with excess demand – rationing by delay – has become less of an option. The reason is that waiting times to see a doctor or have a procedure have shrunk in recent years as money has poured into the service and Ministers have used targets and sanctions to push providers into speeding the patient journey.
So what does the future hold as GP consortia take control of the purse strings? The answer is that it will be very much like the recent past, only with a harsher fiscal environment. I believe that the GP consortia will follow where the primary care trusts have led – struggling to contain demand and balance their books – using many of the same strategies.
Some of these strategies have not changed since the 1990s, when commissioners became explicit, for the first time in the history of the NHS, about what they would and would not purchase. They issued lists of exclusions, which were, and still are, dominated by cosmetic surgery. More recently some primary care trusts have expanded their lists to exclude, among other things, diagnostic arthroscopy, uvulopalatoplasty for snoring, and dilation and curettage.
Financially, these lists involve the small change of the NHS: no major savings are to be made by excluding the removal of tattoos or buttock lifting. Further, in all cases primary care trusts allow for appeals: for the referring GP (and in some cases the patient) to argue that a particular case is “clinically exceptional.” The proportion of appeals allowed varies. A recent inquiry into the way primary care trusts handle appeals about the use of expensive drugs for end-stage cancer care – drugs either not approved by the National Institute for Clinical Excellence or still awaiting assessment – showed that the proportion allowed ranged from zero to 100 percent.
In making decisions about what should or should not be on the NHS menu, primary care trusts use a variety of processes. There is no national template. NICE recommendations or guidelines are taken into account, and so is other evidence about cost and effectiveness. Other criteria, such as equity and patient acceptability, are also used.
Two more recent developments need noting. The first development is the increasing use of thresholds for treatment – meaning imposing stricter criteria for patients to have procedures such as hip replacements and cataract surgery. For example, in the case of hip replacements, patients in one primary care trust only become eligible for treatment if they score a sufficient number of points on a questionnaire that asks them about their mobility and ability to perform the tasks of daily living.
The second development is the introduction of referral management. This comes in a variety of forms but in essence it involves GP referrals of patients to hospital being screened either by their peers or by a service run by the primary care trust. Here the aim is to discourage unnecessary or premature referrals. To what extent this can be seen as a form of rationing or as a way of promoting effective medicine is an open question.
This last example suggests a degree of convergence between U.K. and U.S. practice. It reminds me of a visit many years ago to a U.S. HMO and my surprise at seeing a battery of nurses screening the referrals of clinicians over the telephone. Further, I wonder how the various exclusions in U.S. insurance policies and health plans compare with the primary care trust lists. I suspect that the U.S. rations health care in a variety of ways even while refusing to acknowledge the fact and while holding up the U.K. as an example of what to avoid.
Rudolf Klein, Fellow of the British Academy, is Emeritus Professor of Social Policy, Bath University, and a visiting professor at the London School of Economics. He is the author of The New Politics of the NHS, 6th Edition (Oxford University Press, 2010). firstname.lastname@example.org.